Respiratory Distress

Hx: 20 yo malepresents in respiratory distress. History from the patient’s family is significant for worsening shortness of breath for a week. He has a history of some form of chronic lung disease that the family notes is not asthma, but is treated with bronchodilators and inhaled steroids. He has been using his home meds without relief for the past 5 days. No fever but there is worsening cough productive of green sputum. Family reports that he went to an urgent care center today and was referred to the emergency department. The patient can not give any more history due to his distress.

General: sitting up in stretcher, leaning forward, in obvious distress

Skin: diaphoretic

HEENT: normal

Respiratory: tachypneic, bilateral end expiratory wheezes, poor air movement, decreased breath sounds on the left, no SQ air, no tracheal deviation. Positive accessory muscle use, tripod position breathing, has difficulty speaking more than one word between breaths.

Pleural effusions (para-pneumonic effusions) are common. Up to 40% of bacterial pneumonia presentations have an associated pleural effusion. Most are small and resolve spontaneously with antibiotic treatment of the pneumonia. However, effusions become complicated when bacteria infect the fluid. They are categorized into three groups:

Uncomplicated effusions : these are sterile, exudative (predominantly neutrophils), and resolve with appropriate treatment of the associated pneumonia. However, ultrasound guided thoracentesis can be helpful in large fluid collections. If drained, fluid should be clear to slightly hazy. Fluid cultures are negative.

Complicated effusions : these reflect bacterial migration into the effusion. Higher neutrophil counts are seen along with other fluid changes such as low glucose, increased LDH (>1000 IU/L), and decreased pH. Bacterial counts are low and cultures are often negative. Complicated effusions do not resolve spontaneously with antibiotic therapy and require drainage. There may be loculations present in these effusions and multiple chest tubes may be required.

Empyema : this represents increased bacterial infection of the effusion leading to development of purulence (pus) in the space, often with locultations and thickening of the pleural lining. Fluid is thick, and opaque. Cultures may be positive however the presence of anaerobic organisms or antibiotic therapy prior to drainage may lead to negative cultures. Consultation with thoracic surgery is recommended as treatment often requires placement of multiple chest tubes, thoracoscopic debridement, and sometimes decortication.

Bacteriology is often mixed in empyema with a combination of aerobic and anaerobic organisms. Staph Aureus, Strep Pneumoniae, Klebsiella, Haemophilus and Pseudoomonas are the most aerobic organisms. Bacteroides and Peptostreptococcus species are the most common anaerobes. The most frequent cause of empyema today is bacterial pneumonia at 70% with previous surgery and trauma representing the remaining 30%.